Access to the PPM Journal and newsletters is FREE for clinicians.
9 Articles in Volume 6, Issue #2
Assessment and Treatment of Chronic Pain
Clinical Drug Testing for Pain Medicine
Epidural Indomethacin Alternative in Adult Onset Diabetics
Focus on Urine Drug Monitoring
Office-based Treatment of Opioid Physical Dependence
Oxycodone to Morphine Rotation
Pain Care at the End of Life
Tennant Blood Study, A Summary Report
The Psychiatric Model of Treating Chronic Pain

The Psychiatric Model of Treating Chronic Pain

Psychiatric illnesses do not need to be present in order for the psychiatric model to be successfully used in achieving the multidisciplinary goal of biopsychosocial balance.

A chronic pain patient returned from a period of treatment with another physician. He told me “it was different, it was different in what came across the desk.”

The literature and many patients’ personal reports strongly suggest the co-existence of both a medical model and a psychiatric model in the treatment of chronic pain. These two concepts—which often overlap but which are so psychodynamically different—have not been adequately defined. Most physicians, including some psychiatrists, primarily embrace the medical model. While many patients adequately benefit from just the medical model, others need at least some aspect of the psychiatric model.

The psychiatric model does not necessarily imply that a psychiatric problem exists. However, a concurrent psychiatric illness may exist, including quasi-psychiatric problems such as iatraddiction/pseudoaddiction or other Axis IV problems. The psychiatric model concept evolved following requests for psychiatric consultations because of fears that the pain was being malingered or exaggerated.

The psychiatric model is a style and philosophy of approach, with an intimacy that might be uncomfortable for many physicians. It usually begins following a failure of the typical multidisciplinary clinic approach to pain control. Being sensitive within the medical model to a patient’s psychological needs does not necessarily rise to the level of an active psychiatric treatment model.

The psychiatric model returns medicine to the Greek ideal of studia humananitatis: that of seeking a sound mind in a sound body. In doing so, this model is very eclectic, yields to result-driven interventions, and is notably marked by the continuous and direct physician teaching of skills to control the pain through the use of medications, reflection, mutual education and sharing of information, ego lending, and modeling. This is what the above patient meant about what “came across the desk.”

The Psychiatric Model

Typically, the psychiatric model starts with the assumption that prior treatments failed even with accurate medical diagnoses. As such, a de novo medical diagnoses is not needed.

The DSM-IV offers three pain disorder possibilities.1 The first is psychogenic pain, the second is pain from a mixture of physical and psychogenic etiologies, and the third category (which is coded as a medical condition) is pain with minimal or no psychological basis to its onset or maintenance. Work with the third category focuses on helping a psychiatrically normal person develop life strategies to function as a chronic pain patient, including any potential emotional decision making2 or reactive psychiatric problems resulting from under-treated pain. A distinguishing attribute of this third group is reflected in how they functioned in life before the chronic pain existed. These three groups can, at times, be managed within the multidisciplinary component of the medical model.

The psychiatric model starts as the multidisciplinary approach fails. One physician begins to singularly treat both the physical and emotional-situational issues of recalcitrant pain. The practice of referring a patient to a psychologist or social worker, appropriate under the multidisciplinary approach that follows Bonica’s innovative approach,3 reflects a psychiatric sensitivity but does not mean the psychiatric model is active. Such referrals reduce the first-hand experiential harmonics that so enrich the psychiatric model’s doctor-patient therapeutic relationship. Likewise, merely prescribing antidepressants or referring to a mental health professional to address, for example, a depression does not necessarily invoke the psychiatric model. Some multidisciplinary approaches fail because they are too fragmented, limited, or mechanical to meet the patient’s needs.

The psychiatric model often maintains hope after the medical and multidisciplinary model fails. It remains realistic but stalwartly supportive even in the face of complicated financial and clinical conditions. For a patient, the inability to find such adequate and dependable care can be as emotionally destructive as the pain itself. Keeping hope alive is itself a process which strengthens and heals. Indeed, prolonged positive emotional experiences of hope and support, above and beyond any possible placebo issues,4-6 can effectively reduce and modify the actual brainscape effects of chronic trauma (i.e., pain) or other negative experiences.7,8 Long term interventions, which calm the biological regulatory systems of both physical and emotional states, may be one of the mechanisms which allows medication doses to drop over time.9 The physician must be like the Wizard of Oz who offers a heart, a brain, courage, and hope. Many physicians draw on more of the psychiatric model’s techniques than they realize.

Pain treatment relationships, that begin with rigid written treatment contracts, act to police treatment unlike that in any other area of medicine. The psychiatric model, however, through its distinctive dialogue, uses the patient’s commitment to honesty as the “contract.” A simple and signed agreement to follow treatment recommendations ought to be sufficient. Any improper medication use must be therapeutically, but vigorously addressed in a manner identical to any improper behavior. The underlying reason, if possible, has to be treated. Addictionology consults are often inconclusive since good addicts can deceive even experienced forensic evaluators. A 45-year old teacher said “my doctor ought to spend time to know me…it shouldn’t come from another doctor who only saw me one time…why can’t he figure me out himself?”

The psychiatric model often lives in the zone just beyond the limits of hard clinical knowledge, and therefore commonly cares for those for whom no other standard diagnosis or treatment exists. Far too many patients report that doctors dismiss them once these doctors believe no more can be done for the them. The psychiatric model is historically steeped in the chronic management of such poorly responsive and difficult conditions. The patient may have to continue to live in pain, but he doesn’t have to feel alone.

Often the psychiatric model practitioner is clearly more comfortable and skilled with non-average medication doses and, as such, may be more aggressive with medications, even with opiates. Being comfortable enough to responsibly go to aggressive levels of care, or as one patient said, “having the courage to treat me,” should mean that the doctor is comfortable and very familiar with the patient’s biopsychosocial configuration.

The psychiatric model may also settle issues in the person’s life to the point that a return to the purely medical model is possible.

“Many pain patients speak of physicians who arbitrarily limit the upper dose of pain medications which adds to their hopelessness and suffering and which may produce a transfer into the psychiatric model.”

A patient felt that while his chart’s medical notes read like a “physiology manual,” his psychiatric notes captured how “the doctor himself and I dealt with the pain in my life…it was my biography.”

Opiate Use

Prescribing opiates ought not to be any different than using any other psychoactive drug. They do not reverse the core pathology but they do diminish the suffering and improve the quality of life. This alone allows “healing” of less defined but associated psychic processes which often eventually result in a reduction of pain and opiate use.

Many pain patients speak of physicians who arbitrarily limit the upper dose of pain medications which adds to their hopelessness and suffering and which may produce a transfer into the psychiatric model. Under-prescribing is as irresponsible as unchecked overdosing. Information now exists on genetic polymorphism in narcotic dosing,10,11 long term opiate use and brainscape changes,12,13 and the critical mixing in of some on-going and non-placebo based hope in a treatment plan.14 Physicians who discuss such variables with patients make them feel that treatment is being humanized and individualized to accommodate real needs and real science. Some patients need to be taught and allowed to experience how to judiciously use narcotics. This process also prepares patients to deal with people who may not be as opioid-friendly or opioid mature. Such direct education by—and interaction with—the physician is the distinguishing and enormously therapeutic element of the psychiatric model.

Treating a Non-psychiatric Patient Psychiatrically

When patients fail to get pain relief, the tendency is too often to slide that failure under the “responsibility” of some oblique or undervalued psychiatric component. A psychiatric mitigator is, of course, possible but this assumption might be dangerously over-simplistic. Such a diagnostic assignment must pass many validating tests, such as how discomfort is habitually articulated in the patient’s usual personality without the significant levels of co-morbid physical pain.

The psychiatric model encourages a supra-medication doctor-patient relationship that can be as remedial as any prescription. Patients expect that many physicians are generally not involved in a patient’s lives much beyond the disease state. But one patient told me that “I’m not a neuropathy case. I’m Bill, with neuropathy, who can’t walk for very long, the pain won’t go away, and I hate that.…I need more honest talk time with the doctor…” The medical model has precincts that limit the physician’s input to an emotionally immature level.

Patients with a drug abuse history who need narcotics for pain control offer their own challenges. Many professionals shy away from this group. However, a prior history of addiction may, in fact, be no more than a historical note when faced with chronic pain. The psychiatric model can treat these people because treatment—if resources exist to fund the treatment—will include ego-strengthening and life-restructuring, in addition to teaching the patient how to experience the once abused narcotic in a new and therapeutic way.

“The psychiatric model is marked by a much closer and more direct level of physician interaction with the patient than most physicians have with their patients.”

Addicts use drugs to escape from life, but pain patients use medications to re-join life. A former heroin user knew his current problem was post-accident pain, but now he needed narcotics for a completely opposite purpose than when he used heroin. Years of successful psychiatric model treatment with him confirmed this.

Many drug abusers had suffered psychological abuse or anguish which caused the original drug abuse. They should not have to fear further discrimination or continued punishment when needing pain control treatment. Any deception by the patient opens the door for a psychiatric model physician but, too often, it closes the door for the medical model physician. The psychiatric model’s mandate is more forgiving because it also tries to repair more than the physical pain symptoms. Many times, with prolonged treatment and a good psychotherapeutic component to the pain treatment, this goal is achieved.

One clear example of the psychiatric model’s historical development rests in the iatraddiction-pseudoaddiction saga. Pseudoaddiction15 is an iatrogenic condition stemming from problems best qualified under an Axis IV listing. These behaviors are forced into a patient’s life when the care-providing community imposes suboptimal care. Behaviors may appear to be addictive or drug seeking, but patients are really only seeking “adequate” treatment. Such behavior is phenomenologically similar to typical addictions, but the motivations are not, so the prefix of “pseudo” was added to the word addiction. However, exchanging “iatro” for “pseudo” does more than describe the behaviors—it assigns an etiology and better reprimands the real triggers.16 Explaining iatraddiction to patients often results in cathartic applauses.


Traditional physician interventions focus on procedure- or medication-limited issues. That is the medical model. By contrast, the psychiatric model is more akin to a traditional psychiatrically-styled physician-patient relationship for the patient whose needs are more unique, intense, complicated, inexact, and who do not respond to the typical interdisciplinary pain treatment protocols. The psychiatric model is marked by a much closer and more direct level of physician interaction with the patient than most physicians have with their patients. Thus the psychiatric style of a physician-patient interaction is the single practitioner’s implementation of the multidisciplinary goal of having a biopsychosocial balance. Psychiatric illnesses do not need to be present in order for the psychiatric model to be used. In fact, many physicians employ elements of the psychiatric model more than they may realize.

Last updated on: January 4, 2012
close X